Sole Parent Support application

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1 Sole Parent Support application Why not apply online? Go to If you need more information go to our website or call us on We suggest that you read the instructions on pages 1 to 4 of this application form before starting to fill it in, so you get a feel for what is needed. Support we can give sole parents Sole Parent Support is a benefit that: helps parents get ready for future work (if their youngest child is younger than five years) supports parents to find part-time work (if their youngest child is five years or over) provides financial help through a weekly payment. To get Sole Parent Support you must be: aged 19 years or older a parent or caregiver who has one or more dependent children aged under 14 years in your care not in a relationship and without adequate financial support prepared to meet your obligations and complete the activities Work and Income requires. You need to meet some other conditions. The information we collect on this application form will help us work out what assistance we can give you. What you need to do next You need to do several things before Work and Income can help you. 1. Carry out any activities we ask you to do to help you prepare for or find work. 2. Fill out this application form. 3. Get other people to fill out parts of the application form, if you need to (for example, if you are applying for a Disability Allowance, a registered medical practitioner needs to fill out the Disability Allowance medical certificate). 4. Collect all the documents you need to show us. We tell you about these documents in the application form (look for the ), and we also have a list on pages 3 and Bring this application form and the documents to a meeting. If you do not already have a meeting arranged, contact us on so we can set one up for you. You must give us all the information we need. If you do not have all the information we need, talk with us and we may be able to help. If we find out later that any information you give us is not true, or that you knew information you should have told us and did not tell us, we may stop paying your benefit. You might need to pay money back, we may impose a penalty, and you could be prosecuted. Instructions Page 1

2 What you will find in this application form This application form is made up of: an applicant form (pages 5 to 18) three extra help forms for Accommodation Supplement, Temporary Additional Support and Disability Allowance (pages 19 to 28) obligations section this lists the obligations you must agree to in return for getting payments and what will happen if you do not meet these (pages 29 to 31) Privacy Statement this is what we do with the information you give us (page 32) signature page this is where you agree to meet your conditions of benefit receipt (pages 33 and 35) Helper s statement to be completed if someone has filled in the application form on behalf of you (page 36). How to fill in this application form Tick the small square boxes. For example, if your answer to a question is, tick the box next to the word. Write in the longer boxes. If you do not have enough room to write the answer to a question, use another piece of paper and attach it to the form. Often this form tells you what to do next If you see Text that tells you what to do next we want you answer in the following spaces. If you see Go to question # go to the question number given. If we do not give you a question number to go to, answer the next question. We use the following to show when we need documents and to help you answer questions Documents you need to bring. Information about a question. How to answer a question. If you have someone fill in this application form for you, that person must fill in and sign the Helper s statement on page 36. The better the information you give us, the sooner we can process your application. So, please fill out the application form carefully, and bring all the documents you need to your meeting. Page 2 Instructions

3 Sole Parent Support what to bring Once you have filled out the application form, use this checklist to tick off all the documents you need for your meeting with us. Talk to us if you do not have any of the documents, have given them to us recently or if there might be a delay in getting them. What you need to bring Information NOTE: Documents need to be originals, or copies of documents that have been certified as a true copy by a Solicitor/Lawyer, tary Public, Registrar of the Court or Justice of the Peace. Proof of who you are: If you were born in New Zealand, bring one type of official identification that has your full legal name and your date of birth (for example, your birth certificate, passport, driver licence, firearms licence, deed poll). If you were born overseas, bring proof that you have a right to live in New Zealand (for example, a citizenship certificate, a New Zealand passport, a passport from another country with residence class visa or proof of permanent residence). If your name has changed, bring your marriage certificate, deed poll, or other proof of the name change. All people applying need to bring two more documents that help to prove who you are (for example, a marriage certificate, bank statement, phone or power account, driver licence). A form or letter from Inland Revenue showing your tax number. Proof of your bank account details, such as a bank statement or deposit slip. One of the documents you bring must be at least two years old. What to bring Page 3

4 Applicant forms Depending on your answers in the applicant form (pages 5 to 18), you may need to bring: Proof of your assets and their value. Proof of payments, if you receive a benefit, allowance or pension from overseas. Full birth certificates for each dependent child in your care. Your marriage or civil union certificate, for a current relationship. Your business accounts, if you have your own business. Proof of any before-tax income for the 52 weeks, before the application (for example, wages, holiday pay and any other income) and details of your income for the last 26 weeks. Trust documents, if you are involved in a trust (for example, trust deed, deed of debt, gift statements, accounts). Extra help forms Depending on your answers in the extra help forms (pages 19 to 28), you may need to bring: If you are applying for a Disability Allowance: proof of health related costs a Disability Allowance medical certificate for each person you apply for. If you are applying for an Accommodation Supplement: proof of accommodation costs proof of your assets and their value. If you are applying for Temporary Additional Support: proof of any essential ongoing costs proof of accommodation costs proof of your assets and their value. Page 4 What to bring

5 Sole Parent Support applicant form In the applicant form, you, your, and yourself means the person applying for Sole Parent Support. Tell us about yourself If you have received a benefit or extra financial help from us before, write your client number here if you know it. This number can be found on your Community Services Card if you have one. Client number Tell us the names you have been known by 1 What is your full name? Mr Mrs Ms Miss Other First and middle names Attachment for q1: Bring proof of your identity. What you need to bring is explained on page 3. 2 Surname or family name Is the name on your birth certificate the same as above? Tell us the name that is on your birth certificate First and middle names Surname or family name How to answer q3: For example, have you had married names, English names, changes by deed poll, or aliases? Attachment for q3: Bring your marriage certificate, deed poll, or other proof of any name change. 3 4 Have you ever been known by any other name? Write them all out below What name would you like us to call you? The name I wrote in Question 1 The name I wrote in Question 2 Other Write the full name Applicant form Page 5

6 Tell us more about you 5 6 What date were you born? Day Month Year Are you: Male Female Attachment for q7: Bring a form or letter from Inland Revenue showing your tax number. Attachment for q8: You will need to provide proof of your bank account details, such as a bank statement or deposit slip. 7 8 What is your Inland Revenue tax number? What bank account would you want your payments to be paid into? The account is in the name of: The account number is: Bank Branch Account number Suffix Tell us how we can contact you 9 Where do you live? Flat/House number Street name how to answer q9: If you live in a rural area, flat/house number could include your RAPID number, fire number, emergency services number. how to answer q10: 10 Mailing address can include a postal box (PO Box), rural delivery details, or C/O address. Suburb Town/City Is your mailing address different from where you live? Tell us your mailing address how to answer q11: Please only give us contact details you would like us to use. 11 How else can we contact you? Home phone ( ) Tick the best way for us to first contact you Mobile phone ( ) Other mobile phone ( ) Fax ( ) 12 Do you agree to get s from us? Tell us your address I don t have an address Page 6 Applicant form

7 Tell us your ethnicity Information for q13: We collect this information for statistics that we use in research and future development work. 13 Tick the group(s) you most identify with. Māori New Zealand European Which tribe(s) or iwi? Niuean Samoan Indian Other European Tokelauan Tongan Chinese Cook Island Māori Other Please write below Do not want to answer Tell us about your residence status how to answer q14: This means that you consider New Zealand your home, you are a legal resident, you usually live here and you intend to stay. Attachment FOR Q14: If you answered you will need to provide proof of your assets and their value (page 18) Do you usually live in New Zealand? What best describes your residence status in New Zealand? Tick only one box. New Zealand citizen by birth Granted New Zealand citizenship Granted permanent residency Go to question 18 Date citizenship granted Go to question 16 Date permanent residence granted Go to question 16 Day Month Year Day Month Year Other What is your residence status? 16 When did you arrive in New Zealand? Day Month Year 17 What country were you born in? how to answer q18: Please answer even if you are a New Zealand citizen by birth. 18 Have you lived in New Zealand continuously for at least two years since you became a New Zealand citizen or permanent resident? Attachment FOR Q18: If you answered you will need to provide proof of your assets and their value (page 18). Applicant form Page 7

8 Tell us if you have lived or worked overseas Information for q19: Periods of overseas residence may: affect entitlement to some benefits mean you are eligible for an overseas benefit or pension. For more information, phone Have you ever lived or worked in any countries outside of New Zealand? Go to question 22 Please list details below Name of country Date you entered this country Date you left this country Reason for being in this country how to answer q19: Your reason for being in a country may be that you were there for a working holiday, you were living there, you were born there. 20 Do you receive or qualify for a social security benefit, pension or allowance from overseas? Go to question 22 Tick the box that best describes your benefit, pension or allowance Retirement or old age Superannuation Disability or health condition Widow or survivor Child or dependent War related Other Attachment for q21: You will need to show us evidence of these payments, such as a pension certificate. 21 If you ticked for question 20, please give details of the payments you receive. Payment 1 Payment 2 What country does the payment come from? How much do you receive each time the payment is made (in overseas currency)? Is this amount before or after tax? How often do you receive the payment (for example: weekly, fortnightly, monthly)? What is the name of your pension, allowance or benefit? What is the payment reference number? Tell us whether you are a veteran 22 Have you served with the New Zealand Armed Forces? If you have ticked, you may be entitled to a: Veteran s Pension (for more information call ), and/or a War Disablement Pension or associated payments (for more information call Veterans Affairs New Zealand on VETERAN ( )). Page 8 Applicant form

9 Tell us about the people in your household Tell us about your dependent children 23 Who are the dependent children in your care? Child 1 Please provide details below how to answer q23: Please give the names of children you support financially and who live with you as a member of your family, including: your own children adopted children stepchildren children at boarding school grandchildren / mokopuna. The child s name should be the same as on the child s birth certificate. Tell us the names of all parents of each child. Attachment for q23: Bring the birth certificate for each dependent child. Full name Relationship to you Parent 1: Full name Child 2 Full name Relationship to you Parent 1: Full name Child 3 Full name Date of birth Parent 2: Full name Date of birth Parent 2: Full name Date of birth Relationship to you Parent 1: Full name Parent 2: Full name Child 4 Full name Date of birth Relationship to you how to answer q24: Record the names of all known parents, including those: named on the child s birth certificate named in a Deed of Acknowledgement of Paternity, or 24 named as the child s parent by the Court. Information for q25: 25 You may need to complete a Child Support application for each dependent child. Parent 1: Full name Have you named all the parents for each child? Please talk with us Parent 2: Full name If you need to include more than four children in your application, please write these details about each one on a separate sheet of paper, and bring them with this application form. Have you applied for Child Support for each child? Please talk with us Applicant form Page 9

10 26 Do you have a shared custody arrangement for any of your dependent children? Please list the details below Name of child Hours per week in your care Name of person you have shared custody with Information for q27: 27 A family tax credit is a payment to families with children to help with day-to-day living costs. People receiving a benefit who have dependent children generally qualify for family tax credits. If you qualify for any family tax credit do you want it paid with your benefit? If you tick, we will tell Inland Revenue for you so you do not need to. Tell us about other children that were dependent on you 28 Have you had any children in your care in the last 52 weeks who are no longer dependent on you? Please list the details below Name of child Date of birth Date they became no longer dependent Tell us about your relationship status how to answer q29: Tick this statement to confirm you understand the definition of a relationship for benefit purposes. If you do not understand what we mean by a relationship please leave this blank and talk with us. In the meantime, go to question Definition of a relationship for benefit purposes Whether people are single or a couple affects eligibility for certain income assistance and the rate at which we can pay that assistance. When we determine your entitlement to income assistance, we will consider you to be in a relationship if you are married, in a civil union, or in a de facto relationship. There also needs to be a degree of companionship in which two people (of the same or opposite sex): are committed to each other emotionally for the foreseeable future and are financially interdependent on each other. To give you a better idea of what we mean by this, think about whether: you live together at the same address most of the time you live separately but stay overnight at each other s place a few nights a week you share responsibilities, for example bringing up children (if any) you socialise and holiday together you share money, bank accounts or credit cards you share household bills you have a sexual relationship people think of you as a couple you give each other emotional support and companionship your partner would be willing to financially support you if you couldn t support yourself. Do you understand our definition of a relationship? I understand the definition of a relationship for benefit purposes Page 10 Applicant form

11 30 Do you have a partner? By partner we mean someone you are in a relationship with. If you are not sure, please leave this section blank until you talk to us and in the meantime, go to question 50. Go to question What is your partner s full name? 32 What is your partner s date of birth? Attachment for q33: Bring your marriage or civil union certificate for your current relationship Day Month Year What is your relationship status with this partner? Tick one of the following boxes Married In a civil union In a relationship Are you living at the same address as your partner? Go to question 50 Why are you living apart from your partner? They are in prison Go to question 50 Date they were imprisoned Day Month Year Other Please explain why below Go to question 50 Tell us about a change in relationship status 36 Are you applying for Sole Parent Support because of a change in relationship status? Go to question 49 For example you have separated from your partner or your partner has died. 37 How has your relationship status changed? Tick the box that applies My partner has died Go to question 38 I have separated from my partner Go to question 42 I have lost the financial support of a former partner Other Go to question 47 Please explain below Go to question 49 Applicant form Page 11

12 Tell us about your partner who has died What was your partner s name? What was the date of your partner s death? 40 Day Month Year Was your partner s death the result of an accident? Go to question Have you applied for accident compensation or are you going to? Go to question 50 Tell us about your separation What is the name of the person you separated from? When did you separate from your partner? Day Month Year 44 Are you and the partner you separated from still living in the same house? Please explain why 45 Please describe below, in your own words, the reason or event in your relationship that resulted in you separating from your partner. 46 What do you consider to be the future of your relationship? Go to question 49 Page 12 Applicant form

13 Tell us about financial support you have lost What is the name of the former partner who was giving you this financial support? When did this support stop? Day Month Year Tell us about someone who knows your relationship status 49 Please provide the details of someone who is willing to give us information about your relationship status in writing. What is their full name? Where do they live? Flat/House number Street name how to answer q49: We may ask this person to tell us about your relationship status in writing. They need to: be 18 years or over have known you for at least two years live in New Zealand not be your ex-partner be outside of your immediate family. They cannot be a: parent or step-parent, in-law child or step-child, whāngai child sibling (brother or sister) grandparent grandchild/ mokopuna. If you cannot provide the details of a person please talk with us. Suburb Town/City What is the phone number we can contact them on? Applicant form Page 13

14 Tell us about your work in the last 52 weeks By work we mean any employment for which you get paid or get other advantages for, such as free or subsidised board, payments in kind, or drawings from a business. Answer this section about your work 50 Have you worked in the last 52 weeks? Go to question 62 Tell us about your current work 51 Are you working? Go to question 56 How to answer q52: By full-time, we mean you generally work at least 30 hours a week. By part-time, we mean you generally work at least 15 hours a week. If you have more than one job please record details of your other employers on a separate sheet of paper. For each job include the information asked for in questions 52, 54 to What type of work do you do? Full-time Part-time Casual Seasonal Self-employed Voluntary Do you pay for childcare while you are working? Please tell us how much you pay Weekly Fortnightly Monthly Who are you working for? Employer s name Employer s address Employer s phone number Employer s and fax How to answer q55: 55 Include the amount you are paid and also the value of things you get from your employer instead of money. If your income varies week to week provide an average (for example the average of your last four weeks pay). How much are you paid each week? Type of payment (include goods or services) Amount before tax Amount after tax Page 14 Applicant form

15 Tell us about any work during the last 52 weeks that has finished Have you had any work in the last 52 weeks that you are no longer doing? Go to question 62 Who did you last work for? Employer s name How to answer Q57: If you have had more than one job end in the last 52 weeks please record details of all other employers on a separate sheet of paper. For each job include the employer s: name address phone number 58 and/or fax, and the job s start and end dates. 59 Employer s address Employer s phone number Employer s and fax How long did you work there? Date you started work Day Month Year Why did this work end? Date of last day at work Day Month Year how to answer q60: Holiday pay includes long-service leave payments and termination pay includes payments in lieu of notice. 60 Did you get any of the following payments when you left? Go to question 62 Please tick the box and write in the before-tax amount Sick pay Holiday pay Termination pay Redundancy pay Other How to answer q61: Don t include any of the payments you received in Q How much was your pay for the four weeks before you left? Before tax After tax Applicant form Page 15

16 Tell us about your income and assets Tell us about income in the last 52 weeks? Attachment for q62: Bring a copy of your business accounts. 62 Did you get income from any of the following sources in the last 52 weeks? Wages or salary Termination pay Redundancy pay Accident compensation (eg ACC) Income insurance (replacement/protection) Farm or business income Payments from self employment or contract work Interest from savings, investments, or bonds Dividends from shares, unit trusts, or managed funds Income from rents Payments from boarders or flatmates Child Support payments Other income for a child Maintenance payments Payments from a former partner Student Allowance, scholarship, or Student Loan living cost payments Overseas pension, benefit or allowance payments Other superannuation or retirement scheme income (government or private) Income from an estate, if you have inherited money Income from trusts Other Attachment for q63: You need to show us proof of income you have received in the last 52 weeks and details of your income for the last 26 weeks. 63 Did you answer to any of the sources of income listed in question 62? Tell us the total before-tax amounts, for the last 52 weeks Where did the income come from? Amount before tax Page 16 Applicant form

17 how to answer q64: Other types of payment include advantages such as free or subsidised goods and services (for example, free food, subsidised accommodation). 64 Did you get other types of payment apart from money in the last 52 weeks? Please tell us about the type of payment and its value Type of payment Where did it come from? Its value How to answer q65: How often do you expect the payment, such as weekly, fortnightly, monthly, one-off. The types of income you need to include here are listed on page Do you expect to get income or other payments in the next 52 weeks? Please write the details below. Tell us the before-tax amounts Where will the payment come from? How much will the payment be? How often do you expect the payment? Are you involved with a trust? ATTACHMENT for q66: You will need to show us trust documents; such as the trust deed, deed of debt, gift statements, accounts. 66 Are you involved in a trust, or have you ever been involved in a trust? Involved means one or more of the following: you have set up a trust, usually by making a gift of assets or property you have transferred assets to a trust you make decisions about managing a trust you benefit from a trust; for example, by receiving income such as trust distributions. Name of trust Please write the name of the trust Applicant form Page 17

18 Tell us about your assets Attachment for q67: You may be asked to provide proof of your assets and their value. 67 Do you have any of the following cash assets? Money in bank or other savings Bonus Bonds, shares, debentures or stocks Money lent to other people or organisations Other cash assets 68 If you answered yes to any of the assets listed above, please write the details below. Type of asset You Jointly owned how to answer q69: Examples of property you don t live in include, land, holiday homes, bach/crib, investment properties. 69 Do you have any of the following non-cash assets? Property you don t live in Boat or caravan Other Attachment for q70: 70 You may be asked to provide proof of these details. If you answered yes to any of the non-cash assets listed above, please write the details below. Type of asset How much is it worth? How much do you owe on it? Page 18 Applicant form

19 Extra help form: Accommodation Supplement The Accommodation Supplement helps with rent, board, or home ownership costs. Tell us if you want to apply 71 Do you want to apply for the Accommodation Supplement? Go to question 87 If you answered you will need to provide proof of your assets and their value (page 18). Tell us who you live with 72 Do you live alone? Please write below the names of the others you live with First name Surname or family name Relationship to you Tell us about rental accommodation costs Information for Q73: By rent we mean the amount you pay is for your accommodation only and does not include other costs such as food or electricity. ATTACHMENT for Q76: You may need to show proof of what you pay for rent. ATTACHMENT for Q77: You will need to show proof of what you pay for water rates Do you pay rent? Do you pay rent to Housing New Zealand? Go to question 87. You won t be able to get Accommodation Supplement What is the total amount of rent paid each week for your home? How much of this total amount do you pay for you and your family? Go to question 79 Do you pay water rates separately from your rent? Tell us how much you pay How often? What is the name, address and telephone number of the person you pay rent to? Go to question 87 Extra help forms Page 19

20 Tell us about board costs Information for Q79: By board we mean the amount you pay for your accommodation where it includes food costs and may also include other costs like electricity. How to answer Q79: For example food, electricity, telephone. ATTACHMENT for Q80: You may need to show proof of what you pay for board Do you pay board? Go to question 82 List what costs your board includes What is the total amount of board you pay for you and your family? What is the name, address, and telephone number of the person you pay board to? Go to question 87 Tell us about home ownership costs How to answer Q83: 83 Only include mortgages you used to buy or alter your home. Include both interest and principal. List any other mortgages such as a second mortgage or revolving mortgage. Do not include contents insurance. ATTACHMENT for Q83: You will need to show proof of your home ownership costs. 82 Do you own the home you live in? Go to question 87 What are your home ownership costs? Who do you pay? First mortgage Other mortgage House insurance Mortgage insurance Rates Ground lease Water rates Body corporate fees How much do you pay? How often do you make the payment (such as weekly, monthly or yearly)? ATTACHMENT for Q84: Bring receipts for any repair and maintenance costs. 84 Did you have to pay for repairs and maintenance to your home in the last 12 months? Please write the total amount 85 Do you have a mortgage from Housing New Zealand? Please write your interest rate % 86 Have you received a rates rebate in the last 52 weeks? Amount Rating year 1 July 20 to 30 June 20 Page 20 Extra help forms

21 Extra help form: Temporary Additional Support Temporary Additional Support helps with essential costs for a short time when you have tried everything you can think of, and still cannot pay for them. Tell us if you want to apply 87 Do you want to apply for Temporary Additional Support? Go to question 109 If you answered you will need to provide proof of your assets and their value (page 18). Tell us about any Working for Families Tax Credits you get 88 Do you receive any Working for Families Tax Credits payments from Inland Revenue? tax credit Family tax credit Minimum family tax credit Parental tax credit In-work tax credit Please write the details of any tax credit below Type of tax credit Amount How often? (For example, weekly, fortnightly) Tell us what essential workrelated costs you need to pay to keep working Information for Q90: These are the only work-related essential costs that we may be able to help you with. ATTACHMENT for Q90: You will need to show proof of these costs Are you working? Do you have any of these essential costs that you have to pay so you can keep working? Type of cost Go to question 91 Running costs for a vehicle you use to get to and from work Repayment costs for a vehicle you use to get to and from work Please write the details below Public transport to and from work Telephone, if it is a condition of your work How much is it worth? How often? (For example, weekly, fortnightly) Childcare Extra help forms Page 21

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